Abstract
The past three decades has seen a tremendous rise in black athletes competing at every level of sport. Data from pre-participation programmes have informed our knowledge particularly of black (African/Afro-Caribbean) athletes. It is now well-established that as with white counterparts, black athletes reveal a high prevalence of benign, exercise-related ECG changes, particularly ST segment elevation, voltage criteria for left ventricular hypertrophy and early repolarization. Black athletes also exhibit a higher prevalence of T-wave inversion as well as a greater degree of left ventricular hypertrophy on echocardiogram than white athletes. Such findings overlap to greater extent with primary cardiomyopathies and may contribute to the higher incidence of sudden cardiac death observed in this ethnic group compared to white athletes.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med. 2018;379(6):524–34.
Harmon KG, Asif IM, Klossner D, J a D. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011;123(15):1594–600.
Maron BJ, Carney KP, Lever HM, et al. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2003;41(6):974–80.
Drezner JA, Harmon KG, Marek JC. Incidence of sudden cardiac arrest in innesota high school student athletes: the limitations of catastrophic insurance claims. J Am Coll Cardiol. 2014;63(14):1455–6.
Papadakis M, Carre F, Kervio G, et al. The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011;32(18):2304–13.
Choo JK, Abernethy WB, Hutter AM. Electrocardiographic observations in professional football players. Am J Cardiol. 2002;90(2):198–200.
Magalski A, Maron BJ, Main ML, et al. Relation of race to electrocardiographic patterns in elite American football players. J Am Coll Cardiol. 2008;51(23):2250–5.
Balady GJ, Cadigan JB, Ryan TJ. Electrocardiogram of the athlete: an analysis of 289 professional football players. Am J Cardiol. 1984;53(9):1339–43.
Noseworthy P, Weiner R, Kim J, et al. Early repolarization pattern in competitive athletes: clinical correlates and the effects of exercise training. Circ Arrhythm Electrophysiol. 2011;4(4):432–40.
Corrado D, Pelliccia A, Heidbuchel H, et al. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J. 2010;31(2):243–59.
Sheikh N, Papadakis M, Ghani S, et al. Comparison of ECG criteria for the detection of cardiac abnormalities in Elite Black and White Athletes. Circulation. 2014;129(16):1637–49.
Drezner J, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: the “Seattle criteria”. Br J Sports Med. 2013;47(3):122–4.
Sharma S, Drezner J, Baggish A, et al. International recommendations for the interpretation of the athlete’s ECG. J Am Coll Cardiol. 2017;69(8):1057–75.
Di Paolo FM, Schmied C, Zerguini YA, et al. The Athlete’s heart in adolescent Africans: an electrocardiographic and echocardiographic study. J Am Coll Cardiol. 2012;59(11):1029–36.
Sheikh N, Papadakis M, Carre F, et al. Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population. Br J Sports Med. 2013 Jun;47(9):585–92.
Basavarajaiah S, Boraita A, Whyte G, et al. Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol. 2008;51(23):2256–62.
Rawlins J, Carre F, Kervio G, et al. Ethnic differences in physiological cardiac adaptation to intense physical exercise in highly trained female athletes. Circulation. 2010;121(9):1078–85. https://doi.org/10.1161/CIRCULATIONAHA.109.917211.
Di Paolo FM, Schmied C, Y a Z, et al. The athlete’s heart in adolescent Africans: an electrocardiographic and echocardiographic study. J Am Coll Cardiol. 2012;59(11):1029–36.
Montgomery H, Clarkson P, Barnard M, et al. Angiotensin-converting-enzyme gene insertion/deletion polymorphism and response to physical training. Lancet. 1999;353(9152):541–5.
Killen S a S, Kunic J, Wang L, et al. SCN5A allelic expression imbalance in African-Americans heterozygous for the common variant p.Ser1103Tyr. BMC Med Genet. 2010;11:74.
Van Norstrand DW, Tester DJ, Ackerman MJ. Overrepresentation of the proarrhythmic, sudden death predisposing sodium channel polymorphism S1103Y in a population-based cohort of African-American sudden infant death syndrome. Hear Rhythm. 2008;5(5):712–5.
Porthan K, Marjamaa A, Viitasalo M, et al. Relationship of common candidate gene variants to electrocardiographic T-wave peak to T-wave end interval and T-wave morphology parameters. Hear Rhythm. 2010;7(7):898–903.
Juang JMJ, Horie M. Genetics of Brugada syndrome. J Arrhythmia. 2016;32(5):418–25.
Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes. Heart. 2013;99(6):401–8.
Zaidi A, Ghani S, Sharma R, et al. Physiological right ventricular adaptation in elite athletes of African and Afro-Caribbean origin. Circulation. 2013;127(17):1783–92.
Malhotra A, Dhutia H, Gati S, et al. Anterior T-wave inversion in young white athletes and nonathletes: prevalence and significance. J Am Coll Cardiol. 2017 Jan 3;69(1):1–9.
Ascenzi FD, Anselmi F, Berti B, et al. Prevalence and significance of T-wave inversion in children practicing sport: a prospective, 4-year follow-up study. Int J Cardiol. 2019;279:100–4.
Migliore F, Zorzi A, Michieli P, et al. Prevalence of cardiomyopathy in Italian asymptomatic children with electrocardiographic T-wave inversion at preparticipation screening. Circulation. 2012;125(3):529–38.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Review
Review
1.1 Questions
-
1.
An asymptomatic 15-year-old black athlete underwent pre-participation screening. His ECG is displayed below (Fig. 25.4). What is your advice:
-
(a)
Refer for echocardiogram.
-
(b)
Reassure and consider repeat evaluation in 1 year.
-
(c)
Refer for an exercise test.
-
(d)
Familial evaluation.
-
(e)
Request a cardiac MRI.
-
(a)
-
2.
A black male athlete of north African origin presented with chest pain and the ECG below (Fig. 25.5). Echocardiography revealed good biventricular systolic function with a left ventricular maximal wall thickness of 14 mm. What would you do next:
-
(a)
Perform an exercise test and ambulatory ECG.
-
(b)
Perform a cardiac MRI.
-
(c)
Perform genetic testing.
-
(d)
Perform a cardiac MRI, exercise test and ambulatory ECG monitoring.
-
(e)
Reassure that the LV hypertrophy on echocardiogram is within normal limits.
-
(a)
ECG referring to review question 1
ECG referring to review question 2
1.2 Answers
-
1.
Answer is (b). Anterior T wave inversion (V1-V3) is present on this ECG which affects up to 13% of adult black athletes and is deemed a normal variant when preceded by a convex ST-segment. Among white adult athletes, the prevalence is 0.3%, and given the rarity and extension beyond V2, it warrants further investigation according to the international recommendations [25]. In addition, there are tall amplitude QRS complexes on the ECG that are associated with athletic status and likely lean body habitus.
In those under the age of 16 years, this ECG pattern is considered ‘juvenile’ and does not warrant further investigation in the absence of symptoms or a significant family history. The prevalence of anterior T-wave inversion in those aged 12 years is up to 15% [26]. A study by Migliore et al. reported a prevalence of T wave inversion of 5.7% among 2765 children aged between 8–18 years who underwent preparticipation screening [27]. The majority of T wave inversion (4.7%) was localized to the right precordial leads and considered a juvenile pattern. This was significantly higher (8.4%) in children aged <14 years old but fell to just 1.7% in those ≥14 years and affects just 0.2% of adults.
-
2.
Answer is (d). This patient is symptomatic with chest pain and has an ECG that shows left ventricular hypertrophy meeting Sokolow-Lyon criterion, early repolarization in V3 and V4 with an ascending ST segment morphology, a partial right bundle branch pattern and importantly, lateral T wave inversion in V5-V6 and I and aVL. Additionally, there is an upright T-wave in aVR.
This distribution of T-wave inversion is found in less than 4% of black athletes and prompts further evaluation given the association with hypertrophic cardiomyopathy. Though the left ventricular maximal wall thickness is 14 mm and reflects the upper limit of normal, further assessment with MRI is indicated. This will enable accurate chamber size and wall thickness quantification as well as highlight any abnormal patterns of fibrosis. Ambulatory ECG monitoring and exercise testing will help establish if any arrhythmias are present as well as the haemodynamic response to exercise. Genetic testing may be useful further down the clinical pathway, particularly if a diagnosis is clinically established, though a negative result does not exclude hypertrophic cardiomyopathy.
Rights and permissions
Copyright information
© 2020 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Malhotra, A., Papadakis, M., Sharma, S. (2020). Specific Populations: Athletes of Afro-Caribbean Origin. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_25
Download citation
DOI: https://doi.org/10.1007/978-3-030-35374-2_25
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-35373-5
Online ISBN: 978-3-030-35374-2
eBook Packages: MedicineMedicine (R0)